NCC190664_Notice of Termination_20200117

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/17/2020 4:54:54 PM (NOT Submittal)
Approve by Georgoulias, Bethany 1/22/2020 9:53:53 AM (NOT Request Review- NCC190664)
p The NOT Certification Form was incomplete (box not checked), but the revievver obtained a corrected
copy from the applicant via e-mail. Revised form will be added to the permit records.
• Georgoulias, Bethany reassigned the task to Georgoulias, Bethany 1/19/2020 10:08 AM
• The task was assigned to Farkas, Jim J by round robin distribution 1/17/2020 4:55 PM
• The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: January 22, 2020 5:00
PM 1/17/2020 4:55 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190664
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Chick-fil-A Restaurant at Heritage Village
Address
1010 Forestville Road, Wake Forest, NC
County
Wake
Latitude
35.9459
Longitude
-78.5065
Permittee Listed
Chick-fil-A, Inc.
Legally Responsible
Sandra Moody
Individual
NC Reference No.
NCG01-2019-0664
E&SC Plan ID
2019-00000720
Original NOI
12630
Tracking No.
Date COC Issued
6/20/2019
Prior Rescission
This field will populate only ff OOChas already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation
Supporting upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 1/7/2020
Inspection Approval

Project Close-out TownofWakeForest-certificate-of-completion-
Approval 73.15KB
Chickfila.pdf
Documentation
Mast be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 I, as an authorized representative, hereby request rescission of coverage under
the NPDES Stormwater Permit for the subject facility. I am familiar with the
information contained in this request and to the best of my knowledge and
belief such information is true, complete and accurate.
*This form must be signed by a responsible corporate officer that owns or operates the construction activity, such as a
president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Susannah W. Frost
Title * Executive Vice President
Organization* Chick-fil-A, Inc.
Date * 01 /17/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 8435564261
NOT Certification 2036-not-cfa-signed.pdf 614.06KB
Form Mast be PDF Forrrat